The transobturator outside in suburethral sling insertion procedure.

This video describes the transobturator outside in suburethral sling surgical procedure for the indication of urodynamic stress urinary incontinence. A total of 170 cases were performed from January 2007 till December 2013. The average follow up was from 6 months till 7 years. The cure rate was 90%. There were no recurrences in our series. There was one patient with tape exposure after 3 years which required excision.

INTRODUCTION

Transobturator outside in suburethral sling surgical procedure is used for stress urinary incontinence. We demonstrate the procedure through this video [www.indianjurol.com].

TECHNIQUE

The patient is placed in lithothomy position accentuated by slight hyperflexion and abduction of the hips. The bladder is drained via a catheter. The trocar point entry is identified by locating the adductor longus tendon. Below the tendon, following the genitocrural fold at the level of the clitoris, lateral to the_inferior pubic rami marks the trocar entry points bilaterally. This point reduces the risk of neurovascular bundle injury as it will be is about 1–3 cm away.[123]

A point about 1.5 cm to 2 cm below the urethral meatus and another about 2.0 cm below is held with Ellis or Littlewoods clamps. Saline or adrenaline containing solution can be used to infiltrate this site. The trocar entry points are infiltrated as well. A vertical incision is made between the two clamps. Stab incisions are made at trocar entry points. The two clamps are shifted to the incised edges. The paraurethral tissue is then dissected laterally with Metzanbaum scissors. Dissection is sufficient for the index finger to be pushed to the back of the pubic ramus. The procedure is repeated on the other side.

The first trocar could be either the right or left sided, depending on the surgeon's preference. If the right is chosen, the left hand index finger is inserted through the incision. The finger is directed below the pubic ramus. The helical trocar is kept at 45 degrees to the horizontal plane by the right hand flushed to the thigh. The left thumb is then used to push the trocar into the incision. There will be a distinct feel of perforation of the obturator muscle and membrane. Once this is felt, the trocar is then rotated. The tip of the trocar is felt by the left index finger behind the pubic ramus and it is then guided out by the index finger through the incision. Once the trocar tip is out, a vaginal retractor is used to visualize the lateral fornix as perforation could occur. If this occurs, the trocar is removed and reinserted again; the perforation at the vagina could be left alone if small or stitched to close the perforation.

In this video, the tape used is a Type 1 polypropylene mesh (DesaraR) sling system. Other common tape would be Monarc™ Subfascial Hammock. The tape is attached to the tip of the trocar and the trocar is removed using a reverse rotation motion pulling the tape out. The procedure is then repeated at the contra lateral side. Care is taken to keep the tape flat at midurethra. A diagnostic cystourethroscopy is then done to ensure there are no injuries to the bladder and urethra.

Once placed, the tape is positioned. A Metzenbaum scissors are placed between the tape and the urethra. The plastic sheath and the tape are cut at both ends. Artery clamps are placed on the plastic sheaths and not on the tape. The plastic sheaths are then removed gently to adequately position the tape around the urethra without tension. Once this is done, the tapes ends are cut at the level of skin. The vaginal incision is then repaired with continuous stitch using an absorbable suture. The stab incision is closed with steri- strips.